Alcohol Identification and Brief Advice

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1 Alcohol Identification and Brief Advice Alcohol Identification and Brief Advice (IBA) is an evidence based brief intervention directed at people drinking at increasing and higher risk levels who are not typically seeking help for an alcohol problem. It can be delivered by staff in a wide range of settings. Alcohol IBA interventions support people to understand the impact of their alcohol use and find out where to get help if they need it. There is a significant body of evidence supporting the effectiveness of alcohol IBA. This identifies that for every eight people who receive simple advice, one will reduce their drinking to within lower risk levels. 1

2 Stages of an alcohol brief intervention Throughout the brief intervention remember to: maintain rapport and empathy emphasise the client s personal responsibility for their decisions Raise the issue Do you drink at all? Screen and give feedback Drinking at these levels carries a greater risk of X... Do you think that applies to you at all? Listen for readiness to change What are your feelings about your drinking? What would be helpful to you just now? Choose a suitable approach Use one or more of the following: Information and advice Would you like more information? Enhance motivation What are the pros and cons of your drinking just now? Coping strategies How can you prepare to avoid problems and difficult situations? Build confidence How confident do you feel? What might help? Menu of options What goals might work for you? Exit strategy - remember you or the client can chose not to continue at any point Close conversation It s fine if you don t want to discuss this now, I ll leave this leaflet with you Signpost and/or refer if appropriate 2 NHS Health Scotland, 2011

3 Step 1 - Raise the issue Remember Every Contact Counts You can ask about someone s alcohol use for a number of reasons: It is part of your routine practice - for example as part of an assessment. They raise the subject, or ask for information and advice. An incident occurs that is related to alcohol. A problem or symptom is presented - e.g. debt, arguments, work dismissal or unplanned pregnancy and you are exploring options. You provide a specific lifestyle service that means it is part of your role to ask - e.g. a health check. You have noticed a change in their health or behaviour. Build an alliance for more effective consultations Positive outcomes and higher retention rates have been found to be related to worker s capacity to establish an alliance, as well as to other facets of interpersonal functioning, such as their warmth and friendliness, affirmation and understanding, helping and protecting, and an absence of belittling and blaming ignoring and neglecting and attacking and rejecting (Najavits & Weiss, 1994). 3

4 How to ask: Straightforward: Do you drink alcohol? Directly without judgement: How much and how often? If you think they may be sensitive about it - ask their permission: Would it be OK to ask you some questions about your alcohol use? Is now a good time for you? Ask using empathy and understanding: We have been talking about your low mood/ anxiety/ weight/ relationship problems. Sometimes this sort of problem can be affected by alcohol Do you mind if I ask you a question about your drinking? Some people use alcohol as a way of trying to cope with... Can I ask you about your use of alcohol? How are you coping at the moment Mr Y / Mrs X.? Ask without stigmatising ensure they don t feel singled out and explain why you are asking: In this service we are asking everyone with X condition about their drinking habits because alcohol sometimes makes a difference to your condition. Is now a good time for you for me to ask you about your drinking? At this hospital we ask all patients with X condition about their alcohol use. Do you think alcohol was involved in you being here today? 4

5 Step 2 - Screen and give feedback The purpose of screening is to identify those people with increasing or higher risk drinking patterns who might benefit from an alcohol brief intervention. Alcohol health risks how much is too much? Men who regularly* drink: Women who regularly* drink: over 8 Units per day (over 50 units per week) HIGHER RISK over 6 Units per day (over 35 units per week) over 3-4 Units per day INCREASING RISK over 2-3 Units per day no more than 3-4 Units per day LOWER RISK no more than 2-3 Units per day * Regularly here means every day or most days of the week (not just drinking at these levels once a week). 5

6 Alcohol Use Disorders Identification Test - AUDIT The AUDIT screening tool was developed by the World Health Organisation and is considered the gold standard for screening for alcohol disorders internationally. It is widely used across the UK. The complete AUDIT screening tool is 10 questions long. It can be divided into two parts: AUDIT-C is the first 3 questions and focuses on how much and how often alcohol is consumed. If the score from AUDIT-C is 5 or more, the rest of the AUDIT tool, a further 7 questions can be completed. These further 7 questions focus more on behaviour and the person s subjective experience of their alcohol use. Young people NICE recommends the use of a validated alcohol screening questionnaire such as AUDIT, when working with young people aged 16 and 17 who are thought to be at risk from their alcohol use. With young people under the age of 16 there is no specific NICE guidance relating to the use of identification tools, however it is evident that some professionals are using identification tools with younger people. 6

7 In Plymouth DUST (Drug Use Screening Tool) is the agreed substance misuse screening tool for under 16 s. This gives an indication of risk around a young persons drinking. An AUDIT screen could be used to further understand the young person s alcohol use. There is no weighting on the AUDIT tool, so a 16 year old consuming 15 units a week would elicit the same score as a 45 year old consuming the same amount. When using AUDIT with under 18 year olds, it is advisable to use your professional experience and understanding to consider the level of risk threshold. An approach could be: 0-5 could be lower risk 6-13 could be increasing risk could be higher risk 18 or more could indicate possible dependence Screening tools provide guidance. Continuing to use your professional judgement and experience is key. Providing an alcohol brief intervention for young people under the age of 15 can be much more informal. You could consider using interactive materials such as beer goggles, unit wheels, drink diaries and unit measures. Also don t forget to think about the language being used to ensure it is appropriate for different age groups. 7

8 Completing AUDIT-C Identify the risk level of alcohol intake using the 3 question AUDIT-C. This includes calculating alcohol units with an appropriate This is one tool. unit... Unit measurement is part of the identification process and a key self assessment learning exercise for the client. Half pint of regular beer, lager or cider 1 very small glass of wine (9%) 1 single measure of spirits 1 small of sh This is one unit......and each of these is more than Half pint of regular beer, lager or cider 1 very small glass of wine (9%) 1 single measure of spirits 1 small glass of sherry 1 single measure of aperitifs...and each of these is more than one unit A pint of regular beer, lager or cider A pint of strong/ premium beer, lager or cider Alcopop or a 275ml bottle of regular lager 440ml of reg lager cid How m units di drink to A pint of regular beer, lager or cider A pint of strong/ premium beer, lager or cider Alcopop or a 275ml bottle of regular lager 440ml can of regular lager or cider 440ml can of super strength lager 250ml glass of wine (12%) Bottle of wine (12%) 3 9 How many units did you drink today? 8 250ml glass of wine (12%) Bottle of wine (12%)

9 AUDIT-C Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Scoring system Never 1-2 Never Monthly or less Less than monthly 2-4 times per month Monthly 2-3 times per week Weekly 4+ times per week Daily or almost daily Your score Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. SCORE 9

10 Results of AUDIT-C questionnaire 0-4 If the AUDIT-C score is 0-4, this is defined as Lower Risk drinking. Give positive reinforcement feedback Encourage continued sensible drinking, and end alcohol intervention. 5+ If the AUDIT-C score is 5 or above, Increasing Risk or Higher Risk drinking is possibly indicated. Feed back the results of AUDIT-C and give simple advice using the NHS simple advice leaflet (max 10 minutes). Explain that a full 10 question AUDIT is required for a more accurate result, either in this session or in a follow up appointment. Completing the full AUDIT screening questionnaire Full AUDIT will accurately identify the risk level of alcohol intake. This can take place either: In the same appointment if time allows. In a follow up appointment with the same agency within 2 weeks. In a signposted appointment with a GP. Scoring is the combined total of the 3 AUDIT-C questions plus the total of the remaining 7 AUDIT questions. 10

11 Score from AUDIT-C (Carry forward from previous 3 questions on the other side) SCORE Remaining AUDIT questions Questions How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? Scoring: 0 7 Lower risk, 8 15 Increasing risk, Higher risk, 20+ Possible dependence Scoring system Never Never Never Never Never No No Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Monthly Yes, but not in the last year Yes, but not in the last year Weekly Weekly Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Yes, during the last year Yes, during the last year TOTAL Your score 11

12 Results of the full AUDIT screening questionnaire 5-7 If the full AUDIT score is 5-7, this is defined as Lower Risk drinking. Give positive reinforcement feedback. Encourage continued sensible drinking, and end alcohol intervention If the full AUDIT score is 8-15, this is defined as Increasing Risk drinking. Give feedback using the NHS simple advice leaflet, encouraging a reduction in alcohol intake. Emphasise the risks of continued Increasing Risk drinking, and the benefits of reducing to Lower Risk levels. Follow up in future appointments, to encourage and support lifestyle changes If the full AUDIT score is 16-19, this is defined as Higher Risk drinking. Give feedback using the NHS simple advice leaflet, encouraging a reduction in alcohol intake. Emphasise the risks of continued Higher Risk drinking, and the benefits of reducing alcohol intake and risk level. A referral (or signposting) for an alcohol intervention in Primary Care with a GP is advised. If the client has complex needs a discussion with and possible referral to Harbour Drug and Alcohol Service would be advised. 12

13 Follow up in future appointments, to encourage and support lifestyle changes. If capacity and time allows, use the Brief Lifestyle Intervention tool to help the client to enhance their motivation, and plan for lifestyle changes (allow 40 minutes). Follow up in later appointments to assess and encourage engagement. 20+ If full AUDIT score is 20+, this is defined as Higher Risk drinking, possibly Alcohol Dependence. This indicates that referral for a specialist alcohol intervention in Primary Care with a GP or worker at Harbour Drug and Alcohol Service is essential. Follow up in future appointments, to assess and encourage engagement, and to support lifestyle changes. Complex needs or possible dependence If at any stage the person refuses an appropriate referral or signpost to an alcohol service or intervention, offer an information leaflet giving them contact details for Harbour Drug and Alcohol Service, or offer them the opportunity to return to see you when they are ready. Be aware that you may need to consult with Harbour Drug and Alcohol Service if you identify complex issues, such as past drug use or particular risks or vulnerabilities, even if the AUDIT score is not over

14 FULL AUDIT SCORE ADULT Drinking Pattern Intervention 0-7 Lower risk drinking Alcohol information Increasing risk drinking (Hazardous) Higher risk drinking (Harmful) Consider a number of approaches including simple advice, enhancing motivation, increasing confidence, setting goals, making a plan and identifying coping strategies 20 + Higher risk drinking and possible dependence Signpost or refer to a specialist for comprehensive assessment and treatment Referral Pathways are available in the resources pocket at the back of the guide. 14

15 Step 3 - Listen for readiness to change Feeding back the result of the AUDIT screening tool will raise awareness in the client and help you recognise their readiness for change. For example you may say: How has that left you feeling? What are your thoughts on going to see the alcohol liaison worker? Before change After change R Relapse PC Pre-contemplation Not even thinking about it C Contemplation A Action M Maintenance P The decision threshold Preparation When someone crosses this they start looking for how to change The stages of change model of Prochaska and Diclemente 15

16 Importance In order for us to make changes in our lives the reasons for the change need to be important enough to us before we will make a change. It could be due to health concerns, relationship problems, or many other factors. Encourage the person you are seeing to talk about their reasons for changing. Confidence Alongside an important enough reason to change we also need to believe we can make the change. We will do this in whatever way works for us. It may be through support from friends, family or workers, making plans, preparing, approaching the change in a step by step way or in achievable chunks. 16

17 Step 4 - Choose a suitable approach Information and advice Would you like more information? Tool: Simple advice leaflet / Units in drinks and drinking patterns Enhance motivation What are the pro s and con s of your drinking just now? Tool: Brief lifestyle intervention / To change or not to change Drinking diary / The benefits of change Build confidence What would help you to feel more able to do this? How confident do you feel? What might help? Tool: Brief lifestyle intervention Menu of options What goals might work for you? Tool: Brief lifestyle intervention action plan Coping strategies How can you prepare to avoid difficult situations? Tool: Brief lifestyle intervention action plan 17

18 What you can do in 2 minutes Brief feedback Explain the results of the screening tool. A simple statement such as: The score shows you have an increasing risk pattern of drinking. What this tells us is that you are at risk of developing harm from your alcohol use. You may be experiencing some harm already. Do you have any thoughts about this? Do you have any questions? What you can do in 10 minutes Raise awareness, introduce and evoke change 1. Feedback their drinking pattern - AUDIT score - and any risks or possible harms. 2. Provide alcohol information - units & effects. 3. Ask them: What does this mean to you? Or how do you feel about this? 4. Compare their drinking patterns with those of the general population using the NHS simple advice leaflet. 5. Explore the benefits of reducing - go through the list and encourage them to make some unique to them. 6. Make a plan with them to reduce - what might they do differently? 7. Discuss the targets to aim for - safer drinking guidelines. 18

19 What you can do in 40 minutes Enable a plan to be created 1. Introduction - establish a rapport, discuss confidentiality, explain the session. 2. Typical day - ask open questions about their drinking, gain an understanding. 3. Information exchange - provide information on alcohol, answer questions. 4. Assess how important change is and how confident the person is they can change. Enhance understanding of barriers the patient might feel. 5. Explore the pro s and con s to reducing drinking. 6. Strategies for change - people need to come up with their own ideas to set realistic goals, identify relapse prevention strategies and establish support systems. 19

20 Step 5 - Exit strategy Remember you or the client can choose not to continue at any point. You can close the conversation with: Its fine if you don t want to discuss this now. I ll leave this leaflet with you. It may be appropriate to inform them about another service or help them access a specialist agency. Referral to Harbour Drug and Alcohol Services. 20

21 Alcohol services in Plymouth Over 18 Harbour Drug and Alcohol Services If the AUDIT screening tool results suggest a dependency on alcohol or the person has other complex needs around their alcohol or drug use please contact Harbour Drug and Alcohol Services Ermington Terrace Mutley Plymouth PL4 6QG Tel: Under 18 Harbour Drug and Alcohol Services Hyde Park House Plymouth PL 4 6LF (main office please note young people are not seen at this address) Tel:

22 Useful resources NHS choices Drinkaware Down your drink PHE Alcohol Learning Resources This is a Public Health England resource which provides online resources and learning for those working to reduce alcohol-related harm. It includes a free e-learning training course on alcohol Identification and Brief Advice. National helplines Drinkline Alcoholics Anonymous Families Anonymous Al-Anon Family Groups National Association for the Children of Alcoholics

23 Tools & Resources Tool or resource Photocopy from this guide AUDIT-C and Full AUDIT 4 NHS Simple advice leaflet 4 Drinking diary 4 Units in drinks and drinking patterns 4 Brief Lifestyle Intervention and action plan 4 To change or not to change 4 The benefits of change 4 Unit wheel calculator Unit glass Available from www. Drinkaware.org.uk. Register and they will give you 85 credit for wheels and glasses 23

24 Developed by The Training Exchange Ltd. Designed by JamRox Design.

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